Proximal hamstring tendinopathy treatment

Proximal hamstring tendinopathy (also known as ‘hamstring origin’ or ‘high hamstring’ tendinopathy is probably the 4th most common tendinopathy I see at the clinic (after Achilles, patella and gluteal tendinopathies)

It is a common condition in runners, both distance runners and sprinters.

The basic management that we often use is outlined below, for most people this approach is quite successful. There are of course tricky cases that don’t improve enough to return to their preferred activity even with a good physiotherapy program

Causes

As with other tendon injuries, a relatively high change in load through the tendon over a relatively short time causes the tendon to become ‘angry’. The most common changes of load causing problems are

Increase in uphill running

Increase in amount of ‘fast’ running

Increase in total running volume

Description of pain, and testing

In most cases, scans are not necessary to make a diagnosis or guide treatment in the early phases.

The main complaint is an ache at the lower buttock, which is worse with hillier or faster runs, and is often worse one day after running. Sitting for prolonged periods particularly on hard surfaces is unpleasant.

There are several tests we look at for this condition, including:

Gumboot test

90/90 hamstring contraction

Single leg bridge

It’s important to exclude other causes of pain in this area (there are many!)

To settle

As with many other tendinopathies, hamstring tendons don’t like compression. The hamstring tendon is compressed over the ‘sit bone’ ischial tuberosity in certain positions. Things to avoid include:

Hamstring stretching – this is a big one!

Sitting in low chairs (with the knee above the hip)

Sitting on hard chairs

Other activities such as deep squatting where the hip is bent at more than a 90 degree angle

In some specific cases, medications may be used for a few weeks

Thorough and detailed discussion regarding training load is important to guide future return to sport and determine reasons for onset of the injury

To get back to ‘normal’

It’s important to know that these injuries can take 4-6 months to completely resolve, particularly if they have been sore for a long period. This doesn’t mean this 4-6 months away from sport, however there are often training modifications needed on the road to recovery such as less uphill or fast running

A thorough strength program is the cornerstone of treatment once avoidance of compression has been implemented (as above)

Two exercises we commonly use are:

Prone, isometric hamstring hold

Nordic Curls

The numbers of how many of these we do, and how often, is crucial! It’s important to go quite ‘heavy’ with the weights/exercises, this promotes the tendon to be able to ‘tolerate’ more running etc. There are other hamstring options such as hamstring curl (at the gym) however caution is needed with some of these exercises as they can cause tendon compression

Cross training such as cycling or swimming is generally unlimited during this period.

Addressing any weaknesses in other muscles that assist the hamstring in running is also important for recovery. These include all of the gluteal muscles, calf and back extensor muscles.

Monitoring pain and increasing activity

Tendons generally take about a day to respond to what you do to them. So for a run on Tuesday, we would look at testing (as above) on the Wednesday. Providing pain is no worse one day later, this gives the green light to again increase running volume/speed/hills. Second or third daily running is generally used.

Things that we know don’t help

If someone offers you these, be very cautious! Research shows they are unhelpful at best and detrimental at worst

Injections such as cortisone or PRP (Platelet Rich Plasma)

Stretching

Prolonged rest from all activity (more than 2-3 weeks)

Massage exclusively as a treatment

Good luck and happy return to sport!

Aidan Rich is an APA Sports Physiotherapist at Advance Healthcare Boronia. He has an interst in Sport Physiotherapy, particularly with regards to injuries of the hip and groin, as well as tendon injuries. The Physiotherapy clinic in Boronia in located close to East Ringwood, Bayswater and Croydon.